Page 28 - RTF.24 Employee Benefits

2023 Vision Benefits

Anthem Vision Plan

You have the option to enroll in our group vision plan. The benefits and your contributions are as
follows:
Benefit In Network Out-of-Network
You are strongly Routine Eye Exam (once every 12 months) $20 copay then $42 Allowance
encouraged to use an in- covered in full
network provider to Eyeglass Frames (once every 24 months) $140 allowance $45 Allowance
then 20% off
maximize your benefits remaining balance
and minimize your out- Eyeglass Lenses (one pair every 12 months)
of-pocket cost. To see if • Standard plastic single vision lenses $20 copay then $40 allowance
your provider is in the • Standard plastic bifocal lenses covered in full $60 allowance
network click on • Stnadard plastic trifocal lenses $80 allowance

Provider Network Eyeglass Lens Upgrades $15
• UV Coating
• Tint (Solid and Gradient) $15
• Standard Polycarbonate $15 Discounts on lens
Payment to non- • lenses upgrades not
1
network providers will • Progressive Lenses $0 available out-of-

Standard
•
be based on the • Premium Tier 1 $26 network
$32
Network fee schedule • Premium Tier 2 $38
Premium Tier 3
•
and could result in • Standard Anti-Reflective Coating 2 $45
balance billing. • Premium Tier 1 Anti-Reflective Coating 2 $57
• Premium Tier 2 Anti-Reflective Coating 2 $68
• Other Add-ons and Services 20% off retail price
Contact Lenses (once every 12 months)
Those who prefer • Elective Conventional Lenses $140 allowance $100 allowance
contact lenses over then 15% off
glasses may receive remaining balance

contact lenses instead of • Elective Disposable Lenses $140 allowance $100 allowance
eyeglass lenses and (no add’l discount)
receive an allowance
towards the cost of a • Non-Elective Contact Lenses Covered in full $210 allowance
supply of contact lenses.

Contact Lenses Fitting and Follow UP Member cost up to
•
Standard contact lens fitting
$55
• Premium contact lens fitting $10% off retail
(limitations apply – see certificate for details)

Coverage Election Monthly Salaries EE’s Hourly EE’s
Employee Only $1.90 $0.62 $0.31
Employee + Spouse $3.32 $1.30 $0.65
Employee + Children $3.60 $1.52 $0.76
Family $5.50 $2.24 $1.12

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.